New Medicare Wellness Benefits, New CPT Codes for 2011

Among the many changes that the Affordable Care Act brings to the health care industry in 2011 will be full coverage (no out-of-pocket costs) for a wide range of preventive services to Medicare beneficiaries, including a new benefit: the Annual Wellness Visit (AWV). If you’re a primary care physician, it is safe to assume that you will see an increased volume of Medicare patients seeking these new, complimentary preventive services.

The Centers for Medicare & Medicaid Service (CMS) reveals that there are two types of AWVs: initial and subsequent. Payment for these services will be provided under two new CPT® codes:

For the first visit: G0438 – Annual wellness visit, including personalized prevention plan services (PPPS), first visit; and

These new codes do not replace the “Welcome to Medicare” exam. CMS will maintain coverage for the Initial Preventive Physical Examination (IPPE) or “Welcome to Medicare” exam for new beneficiaries. The IPPE will continue to be coded as G0402 (preventive physical examination; face to face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment). Even though the components of the new AWV are similar to those of the long-standing “Welcome to Medicare” check-up, the two are considered separate benefits and with separate definitions.

For payment purposes, the new codes will be reimbursed at the equivalent of a level four evaluation and management (E/M) visit. In other words, G0438 will be paid at the same rate as a level four, new patient office visit (99204), and each subsequent annual wellness visit (G0439) will be paid at the rate of a level four, established patient office visit (99214).

As with E/M visits, the CPT modifier -25 can be used when medically necessary, significant, and separately identifiable E/M services are provided by the same physician to the patient on the same day as an AWV.

What is an Annual Wellness Visit?

CMS clarified the requirements for a reimbursable AWV. An initial AWV must include:

Establishing the patient’s medical and family history;

Listing current medical providers and suppliers regularly involved in the patient’s care;

Listing risk factors and conditions for recommended intervention, and a list of treatment options.

Subsequent Annual Wellness Visits

CMS also outlined the required elements in a subsequentAWV. These include updating information about the patient’s history, risk factors, cognitive status, and regular medical care providers and suppliers since the prior AWV. The definition also includes furnishing personalized health advice and voluntary advance planning.

For a full listing of the requirements, review CMS’ MLN Matters MM7079 Revised.

Who May Perform the Visits?

Of note is the expansion of the list of providers who may perform an AWV. An AWV may be rendered by a physician or a qualified non-physician provider (nurse practitioner, physician assistant or clinical nurse specialist). In contrast to the IPPE, which can only be performed by a physician or qualified non-physician provider, CMS reveals that an AWV also can be provided by a health professional, defined as a “medical professional including a health educator, registered dietitian or nutrition professional or other licensed practitioner” or by a team of medical professionals working under the direct supervision of a physician. Reimbursement is based on the rendering provider’s National Provider Identification number.

Information to Avoid Denials

If a claim for a G0438 or G0439 is submitted within the first 12 months after the effective date of the beneficiary’s first Medicare Part B coverage, it will be denied as that beneficiary is eligible for the IPPE or “Welcome to Medicare” physical. Furthermore, CMS points out that the G0438 or G0439 must not be billed within 12 months of a previous billing of a G0402 (IPPE), G0438, or G0439 for the same Medicare beneficiary.